Chronic pain after episiotomy caused by scar contracture or neuroma formation remains a serious problem.1 The therapy of choice can be simple resection of the scar tissue with primary wound closure or local flaps. Recovery after these corrections may take time, with the risk of receiving no improvement, more pain, or poor cosmetic results.
We have performed a prospective study with assessment of perineal/vaginal pain and sexual functioning before and after autologous free fat transplantation for correction of scars following childbirth in 20 patients (mean age, 34 ± 7.5 years; mean time after episiotomy, 10.3 ± 2.3 months). Mediolateral episiotomy had been performed in 18 patients. Two patients had pain after perineal laceration. Three patients have had correction of the scars with primary excision and no signs of improvement 6 months ago. All patients reported dyspareunia and other pain-related problems. Lipofilling was performed according to the Coleman technique,2 with scar release and implantation into parallel tunnels on multiple layers under the scars (Fig. 1). A special technique of infiltration with one finger in the vagina and another in the rectum was used to avoid injury of the rectum in case of lipofilling of scars of the posterior wall of the vagina. Perineal pain was assessed preoperatively and at different time points after lipofilling using the short-form McGill Pain Questionnaire, including the Present Pain Intensity index and a visual analogue scale.3 Sexual functioning was assessed with a revised Sabbatsberg Sexual Self-Rating Scale before and after intervention.4 Follow-up of the patients was scheduled after 1, 3, and 6 months. The distribution of variables within the patient group was compared by nonparametric analysis of variance (two-sample Wilcoxon test), and differences between dependent (paired) data were assessed by the nonparametric paired test (signed rank test). A value of p < 0.05 was considered to be statistically significant. An average volume of 12 ± 3 cc of autologous fat was injected (range, 7 to 15 cc). Four patients underwent two lipofilling sessions because of improvement with the first lipofilling but had remaining painful areas in one part of the scar. The average interval between these sessions was 4 ± 1.5 months. All patients made good postoperative recovery without major complications. Eighteen of 20 patients had an immediate subjective improvement of their pain obviously attributable to release of severe scar contractures. One month after lipofilling, the short-form McGill Pain Questionnaire score was significantly reduced in comparison with the score before treatment (p < 0.05) (Fig. 2). Three and 6 months after treatment, the score had decreased further (p < 0.05). The Present Pain Intensity index and visual analogue scale score were also significantly reduced after 1, 3, and 6 months (p < 0.05). The Sabbatsberg Sexual Self-Rating Scale score showed a significant increase after lipofilling (p < 0.05). Fifteen patients were very satisfied with the small operation and five were satisfied.
A number of studies recently demonstrated the reliability, long-term stability, and safety of autologous free fat transplantation in reconstructive procedures.5 In our opinion, lipofilling also seems to be a promising treatment for correction of perineal/vaginal scars after episiotomy and perineal laceration. It is well tolerated and offers encouraging results, with improvement of pain and better sexual function.
Dietmar Ulrich, M.D., Ph.D.
Franziska Ulrich, M.D.
Department of Plastic and Reconstructive Surgery
Lena van Doorn, M.D., Ph.D.
Department of Gynecology
Steven Hovius, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery, Erasmus University Hospital, Rotterdam, The Netherlands
The authors have no financial interest in this research project or in any of the techniques or equipment used in the study. The authors have no conflicts of interest to disclose.
1. Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J Jr, Lohr KN. Outcomes of routine episiotomy: A systematic review. JAMA 2005;293:2141–2148.
2. Coleman SR. Structural Fat Grafting. St. Louis: Quality Medical; 2004.
3. Melzack R. The short-form McGill Pain Questionnaire. Pain 1987;30:191–197.
4. Garratt AM, Torgerson DJ, Wyness J, Hall MH, Reid DM. Measuring sexual functioning in premenopausal women. Br J Obstet Gynaecol. 1995;102:311–316.
5. Lolli P, Malleo G, Rigotti G. Treatment of chronic anal fissures and associated stenosis by autologous adipose tissue transplant: A pilot study. Dis Colon Rectum 2010;53:460–466.
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